HomeMy WebLinkAboutBLD-22-007249 I Office Use Only
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,$O .' R4O Permit#jtl 4 6 L/7 I
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j issue date
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EXPRESS BUILDING PERMIT APPLICATIf E D E I V E D
TOWN OF YARMOUTH -----_- -- ---
Yarmouth Building Department JUN 14 Z�22
1146 Route 28
South Yarmouth, MA 02664 - --
(508) 398-2231 Ext.1261 BUILDING DEPAkTMENTBy.
-
CONSTRUCTION ADDRESS: I a73 r c Z Li Dtbtkio V 1 L
ASSESSOR'S INFORMATION:
�) Map: 1 nyParc1ell:_�, ,t
OWNER: I 150 kS is" exeunt �JaCX�J ICJ 43io n1 OA O'2.lo4 Sa�9`7 (t 3C
NAME PRESENT ADDRESS` TEL. #
CONTRACTOR: Q. S11,SJIZ,l�� e0 • 90 C W ..5 �0.% J•ViaM 11U 1 cd4S"1(00" �pa's-
NAME RNQk Gs\\�S MAILING ADDRESS I TEL.#
❑Residential C1 lit Commercial Est.Cost of Construction$ I 0 0 D. Op
Home Improvement Contractor Lic.# Construction Supervisor Lic.#
Workman's Compensation Insurance: (check one)
❑ I am the homeowner ❑ I am the sole proprietor ❑ I have Worker's Compensation Insurance
Insurance Company Name: Worker's Comp.Policy#
WORK TO BE PERFORMED
Tent ( Duration\``a)- t5 (Fire Retardant Certificate attached?) Wood Stove
Siding: #of Squares g ) 13122._ Replacement windows: # Replacement doors: #
Roofing: #of Squares ( )Remove existing* (max.2 layers) Insulation
Old Kings Highway/Historic Dist. ( )Replacing like for like Pool fencing
*The debris will be disposed of at:
Location of Facility
I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief. I understand that any false answer(s)
will be just cause for denial or revocation/c7 of my license and for prosecution under M.G.L.Ch.268,Section 1. I -
Applicant's Signature: ��.E 1u1S Date: (L1.Kt=
Owners Signature(or attachment) Date: (.40,/5/ _
Approved By: 17.-
PP Date: C
Building Official(or igne EMAIL ADDRES
d---
Zoning District:
Historical District: 0 Yes ❑ No Flood Plain Zone: a Yes 0 No
Water Resource Protection District: Within 100 ft.of Wetlands:
0 Yes 0 No 0 Yes No
. The Commonwealth of Massachusetts
/, Department of Industrial Accidents
=•=e= 1 Congress Street, Suite 100
__ 4__ Boston, MA 02114-2017
r. www.mass.gov/dia
MP
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information PIease Print Legibly
Name (Business/Organization/Individual):1 sv.arut ) Oft f.. /4 1cAL.
Address:
City/State/Zip: Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
3.0I am a homeowner doing all work myself.[No workers'comp. insurance required.]t
9. ❑ Demolition
10 ❑ Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
- 12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp. insurance.1
14.❑Other
6.We are a corporation and its officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no employees. [No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify unde he a�ins aanndlpenalties of perjury that the information provided above is true and correct.
Signature: `F'�''"'' Date: /lylaR
Phone#:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
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